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Thoracic imaging

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DAVID M. HANSELL,1 PHILLIP M. BOISELLE,2 JONATHAN GOLDIN,3 HANS-ULRIK KAUCZOR,4 DAVID A. LYNCH,5 JOHN R. MAYO6 AND EDWARD F. PATZ JR7
Department of Radiology, Royal Brompton Hospital, London, UK, 2Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, 3Department of Radiology, David Geffer School of Medicine at UCLA, Los Angeles, California, 5Division of Radiology, National Jewish Health, Denver, Colorado, 7 Department of Radiology, Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, North Carolina, USA, 4Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany, and 6Department of Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
1

ABSTRACT
The various techniques encompassed in the term Thoracic Imaging have had a dramatic effect on the practice of respiratory medicine over the last 25 years. One of many examples is the increased precision with which lung cancer can be preoperatively staged using CT and PET imaging. The increasing sophistication of thoracic imaging tests brings many benets, but there are caveats. This review considers a selection of techniques and contains state-of-the-art commentaries by distinguished experts on current challenges and likely future developments. Key words: magnetic resonance imaging, molecular imaging, tomography, X-ray computed.

respiratory medicine, is unlikely to be repeated in the near future. However, the rate at which these different techniques continue to be rened is remarkable. CT is perhaps the best model of this rapid evolution. Advances in post-processing of digital data have been crucial and underpin the development of these imaging tests. The extent to which some of the cutting-edge techniques described below will be used in clinical practice in future years is unknown, but such speculation provides a frisson of anticipation.

IMAGING THE AIRWAYS Phillip M. Boiselle

We are in the midst of an exciting airway imaging revolution. The newest, state-of-the-art, 320-detector CT scanners can image the entire central airways in only half a second, allowing for dynamic cine imaging of the trachea and bronchi during respiratory manoeuvres.1 Moreover, advances in post-processing software allow three-dimensional external and internal renderings of the airways to be obtained in mere minutes, as well as detailed quantitative analysis of airway wall thickness and luminal diameters1,2 (Fig. 1). Concurrently, exciting advances in MRI using hyperpolarized gases have enhanced the ability to evaluate regional lung ventilation,3 and PET imaging provides unique metabolic and molecular information about the airways.4 As expected, initial airway imaging research has focused primarily upon technology assessment and has demonstrated a high accuracy of these new methods for detecting diseases of the large and small airways in comparison with reference standards, such as bronchoscopy and pulmonary function tests. More recently, interest has shifted towards the potential overlap between health and disease. For example, several studies of healthy individuals have addressed this potential overlap when using current diagnostic
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INTRODUCTION
The Big Bang of several new imaging technologies (CT, PET, MR, digital radiography), all appearing on the scene in quick succession and all applicable to

D.H. is a consultant radiologist at the Royal Brompton Hospital with a long-standing interest in thoracic imaging. P.B. is current Editor-in-Chief of Thoracic Imaging and has published widely on imaging of the major airways. J.G. is a member of the National Lung Screening Trial (USA) and Vice Chair of the Department of Radiology, UCLA. H.U.K. is Director of Radiology at University Hospital Heidelberg, Germany and has particular expertise in MRI of the lungs. D.L. is Professor of Radiology and Medicine at the National Jewish Health, Colorado and is a world authority on diffuse lung diseases. J.M., Vancouver General Hospital, has had an abiding interest in radiation issues and pioneered the technique of high-resolution CT. E.P. of the Department of Pharmacology and Cancer Biology at Duke University Medical Center, Durham has been at the forefront of molecular imaging research. Correspondence: David M. Hansell, Department of Radiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Email: davidhansell@rbht.nhs.uk Received 9 November 2009; accepted 26 November 2009. (Associate Editor Y.C. Gary Lee) 2010 The Authors Journal compilation 2010 Asian Pacic Society of Respirology

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Figure 1 Post-processing of airways and emphysema in a patient with COPD. (a) Three-dimensional segmentation of central airways. (b) Bronchus intermedius at end-inspiration, showing quantitative measurements of airway lumen and wall thickness. (c) Bronchus intermedius at end-expiration, showing quantitative measurements of airway lumen and wall thickness. (d) Three-dimensional analysis of emphysema, graphically showing size of emphysematous holes and their relationship to the airways. Note colour coding with different colours for each lobe of the lung. (Image analysis performed using commercially available software (VIDA Diagnostics, Inc, Iowa City, IA, USA)).

criteria for tracheomalacia5 (Fig. 2), bronchiectasis,6 and air trapping.7 By demonstrating that healthy individuals with normal pulmonary function may frequently demonstrate substantial dynamic expiratory tracheal collapse, bronchial dilation and air trapping, these studies are leading us away from a simplistic black and white model of health and disease towards a more complex gray scale that takes into account a broader spectrum of anatomical and functional changes in the airways in the absence of clinical disease than was previously recognized. The future of airway imaging will likely involve greater correlation between imaging ndings and genetic predispositions to specic diseases as part of the growing trend towards personalized medicine and early diagnosis.
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In order for anatomical non-invasive airway imaging to reach its full potential, future large-scale, multidisciplinary studies are necessary to accurately quantify its value with respect to patient outcomes and cost-effectiveness. Such studies will ideally demonstrate that non-invasive airway imaging methods improve patient outcomes and reduce health-care expenses by increasing the diagnostic yield and reducing the time of bronchoscopic procedures. Although some of the most exciting advances have occurred in the areas of quantitative and functional airway imaging, these applications are currently niche tests that are available only at specialized centres. The unique ability of non-invasive imaging tests to provide detailed regional information about
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Figure 2 Paired images of upper trachea obtained at end-inspiration (a) and during a forced exhalation (b) in a healthy 58-year-old man with normal pulmonary function. Cross-sectional area of airway lumen reduced from 360 to 64 mm2, consistent with an 82% reduction, a value well above the current threshold of >50% reduction for diagnosing tracheomalacia.

airway structure and function has led to speculation that they will play a more general role in patient care in the future.8 A necessary tipping point for the transition of these tests from niche to mainstream will be their adoption as biomarker end-points for assessing the response of novel targeted therapies for treating airway diseases, such as chronic bronchitis and asthma. As we look towards the future, collaborative and synergistic efforts between radiologists and pulmonologists, scientists and clinicians, and among academic centres, government and industry, will be necessary for the non-invasive airway imaging revolution to be fully realized.

LUNG CANCER SCREENING WITH CT Jonathan Goldin

Lung cancer, despite being preventable to some degree, is the number one cancer killer worldwide. Currently most patients are diagnosed with advanced-stage disease (overall 5-year survival of 16%). When diagnosed at an early stage the 5-year survival rate is 70%.9 Furthermore as the group at most risk is well dened (older, current and previous smokers) and the lung lesions are easily seen on conventional imaging, it would seem obvious that screening for lung cancer should be performed on a routine basis. Worldwide, public policy organizations recommend against screening for lung cancer. With the
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advent of low-dose CT there has been a resurgence of the screening debate.10,11 Central to the debate is the choice of study designs that would best determine the benets, harms and costs of such screening.1113 In the heat of the screening debate, it is also important not to loose sight that tobacco control public policy combined with smoking cessation interventions can reduce lung cancer incidence and mortality without the need or complications of a screening test. CT screening is a far more sensitive method than conventional radiography for identifying small, potentially early-stage, lung cancers. Screening advocates argue that improvement in lung cancer survival, can be inferred by the diagnosis of early-stage lesions, and that this is in itself sufcient evidence for efcacy.12 Other investigators have pointed out that cause-specic survival is an invalid metric of screening efcacy because it discounts other causes of mortality and it introduces biases (lead- and length-time biases, and overdiagnosis).11,14 A screening test, to be of benet, must result in increased life expectancy for individuals with lung cancer. Furthermore, it must be of low morbidity and not have numerous false positives that cause anxiety or require invasive or dangerous follow-up tests. Overdiagnosis is diagnosis of a disease that would not have become clinically signicant had it not been detected by screening.14 Given that the risk population is also at high risk of other comorbid smokingrelated diseases (ischaemic heart disease and emphysema) and because CT can detect small lung cancers that may have very long doubling times,15 overdiagnosis may be a major problem. False positive
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results, reported in up to 74% of screened subjects, may lead to anxiety and invasive diagnostic procedures, such as percutaneous needle biopsy or thoracotomy.16 Another major negative impact of false positives is the anxiety incurred by the screened individual (and their support circle) upon being informed that the screening study was not clear and there is need for some form of follow up. The US Preventive Services Task Force, in making their recent recommendation for lung cancer screening, concluded that they could not determine the balance between the benets and harms of screening for lung cancer.17 It would seem prudent that at this time for physicians to assume the responsibility for informing high-risk individuals regarding the pros and cons of screening for lung cancer and that at present screening is best done in the setting of an ongoing trial.

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MRI OF THE LUNG Hans-Ulrik Kauczor

MRI of the lung has experienced an impressive series of ground-breaking technological developments. Almost all of them are related to imaging speed, gating and signal enhancement (relevant references for the interested reader are1824). The potential of visualizing pulmonary vessels, demonstrating pathological structures and probing pulmonary microstructure has made great progress, thus surpassing projection radiography and rivalling CT. Interpolated volume imaging with high spatial resolution, contrast enhancement, single and multiphasic MR angiography, diffusion-weighted sequences are the drivers in this category. However, the capability of MRI to assess function in a broader sense is its biggest asset. It includes, but is not limited to perfusion and ventilation, including V/Q ratio and match, gas exchange, vascular permeability, ow, shunt, haemodynamics, right heart function, lung volumes and mechanics, and motion. Routine clinical applicability has been demonstrated for contrast-enhanced perfusion MRI and analysis of cardiopulmonary interaction. Whereas multidirectional blood ow measurements, angiogenesis imaging and high-resolution ventilation imaging with hyperpolarized 129 Xenon gas represent recent technological innovations. As such, the broad spectrum of functional MRI of the lung is capable of replacing several diagnostic procedures, such as pulmonary function tests, ventilation and perfusion scintigraphy, echocardiography and uoroscopy. Overall the structural and functional components of MRI of the lung are just a part of whole body MRI that gains more and more attention in congenital anomalies and diseases, thromboembolic disease, oncological staging and systemic inammatory diseases, either infectious (e.g. tuberculosis) or non-infectious (e.g. COPD). Several challenges remain in the translation of novel MR technologies. MRI in general is regarded as an expensive technology. Two major goals need to be
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attained to really change the diagnostic management of patients with lung disease, and these relate to two considerations: (i) planning and monitoring of treatment of at least one major lung disease will substantially benet from the regional functional information provided by MRI; and (ii) MRI will replace traditional diagnostic procedures, such as chest radiography (interpreted by radiologists) and scintigraphy or echocardiography (undertaken by non-radiologists). Clinical applicability will also be determined by availability, speed and workow. The number of MR scanners is limited in most countries and the sessions are mainly lled with MR examinations of the brain, spine, joints or liver. Thus, in the context of existing MR scanners it is extremely difcult to allocate slots for MRI of the lung, particularly when it is perceived to be a time-consuming and difcult examination. However, new protocols are focused on quality, workow and speed, allowing completion of MRI of the lung in less than 30 min. Future developments include imaging of pulmonary and whole body inammation. This might include the implementation of whole body PET/MRI for lung diseases as well as the construction of a dedicated walk-in stand-up MRI scanner for lung examinations.

IMAGING OF DIFFUSE INTERSTITIAL LUNG DISEASE David A Lynch

High-resolution CT has become the pivotal investigation for the characterization of diffuse lung diseases, primarily because of the ability of experienced observers to make condent correct diagnoses of common diseases, such as IPF, sarcoidosis and hypersensitivity pneumonitis (HP). At centres of excellence, where radiologists, pulmonologists and pathologists collaborate, its discriminative ability continues to improve. For example, among the brotic interstitial pneumonias, CT facilitates the distinction between usual interstitial pneumonia (UIP), the brotic form of non-specic interstitial pneumonia (NSIP) and brotic HP.25 UIP is characterized by basal predominant, peripheral predominant reticular abnormality with honeycombing. Idiopathic NSIP is characterized by basal predominant reticular abnormality, with marked associated volume loss and traction bronchiectasis, without honeycombing and often associated with sparing of the immediate subpleural lung.25,26 For the diagnosis of chronic HP, the most helpful CT features are the presence of lobular areas of decreased attenuation and vascularity, centrilobular nodules and the absence of a lower zone predominance of abnormalities.25 However, some overlap persists; in particular there is a substantial subset of patients with biopsy-proven UIP with a CT appearance indistinguishable from NSIP. Because CT provides images of the entire lung, it may provide a better representation of disease than a localized surgical biopsy. In fact, a typical CT appearance of HP or UIP may trump an alternative
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and radiologists are often unaware of CTs high radiation dose and associated risks.32 Diagnostically, CT is unequalled in availability, speed, large eld of view and compatibility with monitoring and life support devices. Low concern for CT radiation dose is understandable given the historic controversy surrounding low-dose (<20 mSv) radiation risk33,34 and the arcane units used to measure radiation dose.35 These measures are not optimized for medical radiation dose measurement and consequently do a poor job in communicating radiation risk to patients and health-care providers. Consequently, radiologists and referring clinicians have seized on CTs diagnostic advantage and paid less attention to radiation dose concerns. The introduction of multidetector scanners with increased capacity to deliver radiation dose has worsened the situation. There are two components to CT radiation dose management, optimization and justication. Optimization, minimizing radiation dose while maintaining image quality, is a well-dened physics/technical problem with few inputs and easily measured outcomes.36 By comparison, justication attempts to separate useful from futile imaging examinations based on the clinical scenario. Justication guidance has poorly dened inputs and is multifactorial; patients concern and preference, referring clinicians requirement for diagnostic condence, radiologists expertise and resource availability. Expert panels have provided imaging guidelines for clinical/diagnostic problems with the primary goal of optimizing the use of radiology services.37,38 They offer the secondary gain of reducing radiation exposure by eliminating unhelpful examinations. Current clinical guidelines are limited by poor evidence on which to assess imaging investigations. This is in marked contrast to the evidence base required for drugs. In the absence of clinical trial evidence, a substantial percentage of imaging guidelines are based on expert opinion, not on documented patient outcomes. Thus in 2010 we nd ourselves at a crossroads. Even with anticipated improvements in CT dose optimization, the radiologic community should view further increases in CT utilization or examination dose with caution. While CT remains a tremendously powerful

pathologic diagnosis.26,27 The shrewd pulmonary pathologist will commonly request a CT interpretation before providing a nal diagnosis, particularly in difcult or confusing cases. Conversely, a radiologist or pulmonary physician interpreting CT images should review available histological data. The most signicant limitation of CT is that expertise in interpretation is generally conned to academic centres. The accuracy and inter-observer agreement of community radiologists (and pulmonologists and pathologists) are substantially lower compared with their academic colleagues.28 This suggests that most patients with diffuse lung disease should be evaluated at least once at a centre of excellence. Accurate diagnosis will become particularly important if and when an effective treatment for IPF is identied from ongoing clinical trials. A further limitation of CT is the subjectivity of visual quantication of disease extent. As effective treatments are identied, accurate quantication of diffuse lung disease on CT will be important for conrming disease progression or improvement, both as a clinical tool and as an outcome measure in clinical trials. Quantitative techniques have evolved from simple histogram-based measures of lung attenuation to more sophisticated methods employing texture-sensitive techniques29 often derived from three-dimensional volumetric CT datasets.30 The ideal quantitative system would be capable of measuring the extent of different patterns of abnormality, including ground glass attenuation, reticular abnormality, honeycombing and emphysema. The system should be relatively independent of image noise, CT reconstruction algorithms and the level of patient inspiration. As more quantitative tools are developed, they must be tested in a well-characterized set of CT data from patients with known outcomes. While the advances in our knowledge of diffuse lung disease are exciting, they are useful only in so far as they have relevance to patient care. Careful outcome-based longitudinal follow-up studies will expand our understanding of the clinical signicance of imaging ndings.

CT THORAX: RADIATION DOSE John R. Mayo

The observation of a sixfold variation in utilization rates (Table 1)31 suggests CT is overused in some jurisdictions. As CT is the most commonly performed high radiation dose examination this causes substantial differences in medical population radiation exposure. In the US current medical radiation exposure is estimated to approach background radiation exposure. Participants at the International Atomic Energy Agency International Workshop on Justication of Medical Exposure in Diagnostic Imaging (Brussels, 24 September 2009) noted no health outcome differences directly attributable to CT usage between high and low utilization countries. Furthermore, it has been documented that referring clinicians, patients
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Table 1 The number of CT scanners per million population and the number of CT examinations per year per thousand population, compiled in 2007 CT examinations per year per thousand population
207.4 53.7 138.3 33.9 57.0 88.9 103.3
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Country
USA England Belgium Denmark Spain Sweden Canada

CT scanners per million population

32.2 7.5 31.6 13.8 13.5 17.8 12.1

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diagnostic tool, the health-care community must restrict use by the awareness of, and implementation of, clinical guidelines. These guidelines have been shown to be most useful when embedded in the consultation request facility of an electronic medical record.39 Further research into the impact of imaging on clinical outcomes is required to improve our available evidence base. Finally, both optimization and justication are team efforts, requiring the combined efforts of the health-care team, medical physicists, regulators and patients.

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MOLECULAR IMAGING IN THE THORAX Edward F. Patz Jr

Radiological studies play a fundamental role in every aspect of clinical medicine. Imaging offers invaluable information in establishing a diagnosis, guiding interventional procedures and directing patient management. Some imaging ndings can be used as prognostic markers or to assess disease status following therapy. While conventional imaging studies provide exquisite anatomic and morphological descriptions, they do not necessarily reect the complex cellular composition of a radiographical abnormality or the lesion phenotype. Consequently, diseases, such as cancer that result from a genetic

abnormality, are not optimally imaged with traditional radiographical studies. A different imaging tactic that incorporates the biology is needed if a greater impact on patient care is to be realized. The concept of a molecular imaging strategy began to emerge in the early 1990s, with the use of PET imaging and the glucose analogue probe, 18 F 2-uoro-2-deoxy-D-glucose (FDG).40,41 This was a new direction for radiology, and early clinical studies primarily in oncology patients showed that imaging could indeed move beyond traditional anatomy and provide basic metabolic and biochemical properties of tumours. As with any other new paradigm in medicine, there was lots of initial excitement with a wide variety of theoretical applications, from a clinical as well as basic science perspective.4244 In the thorax, it was suggested that there would be improved imaging in areas, such as lung cancer (Fig. 3), angiogenesis, gene expression, myocardial ischaemia, tracking stem cells and proteinprotein interactions. This was to be accomplished by the discovery of new molecular targets, innovative imaging techniques and novel disease-specic imaging probes. These discussions, however, were not always guided by a pragmatic view of the clinical needs and how this technology would be integrated into everyday practice. The vision for molecular imaging was not clearly focused, and consequently the eld has moved in many directions.

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Figure 3 Sixty-three-year-old man with an irregular right upper lobe mass on coronal CT (a). Fused CTPET images with two different imaging probes (b,c) provide a tumour prole. Each probe is targeted against a tumour-specic receptor, which conrms the diagnosis of non-small cell lung cancer, and the pattern of uptake suggests the appropriate targeted therapy.
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2 Lynch DA, Newell JD. Quantitative imaging of COPD. J. Thorac. Imaging 2009; 24: 18994. 3 Matsuoka S, Patz S, Albert MS et al. Hyperpolarized gas MR Imaging of the lung: current status as a research tool. J. Thorac. Imaging 2009; 24: 1818. 4 Yerushalmi D, Mullick R, Quon A et al. Simulations of virtual PET/CT 3-D bronchoscopy imaging using a physical porcine lung-heart phantom. Mol. Imaging Biol. 2009; 11: 27582. 5 Boiselle PM, ODonnell CR, Bankier AA et al. Tracheal collapsibility in healthy volunteers during forced expiration: assessment with multidetector CT. Radiology 2009; 252: 25562. 6 Copley SJ, Wells AU, Hawtin KE et al. Lung morphology in the elderly: comparative CT study of subjects over 75 years old versus those under 55 years old. Radiology 2009; 251: 56673. 7 Tanaka N, Matsumoto T, Miura G et al. Air trapping at CT: high prevalence in asymptomatic subjects with normal pulmonary function. Radiology 2003; 227: 77685. 8 Goldin JG. Functional airway imaging methods. In: Boiselle PM, Lynch DA (eds) CT of the Airways. Humana Press, Totowa, NJ, 2008; 95117. 9 Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol. 2001; 2: 53343. 10 Field JK, Duffy SW. Lung cancer screening: the way forward. Br. J. Cancer 2008; 99: 55762. 11 Patz EF Jr, Black WC, Goodman PC. CT screening for lung cancer: not ready for routine practice. Radiology 2001; 221: 58791. 12 Gur D. Lung cancer screening: radiologys opportunity here and now. Radiology 2006; 238: 3957. 13 Reich JM. Assessing the efcacy of lung cancer screening. Radiology 2006; 238: 398401. 14 Black WC. Overdiagnosis: an underrecognized cause of confusion and harm in cancer screening. J. Natl. Cancer Inst. 2000; 92: 128082. 15 Hasegawa M, Sone S, Takashima S et al. Growth rate of small lung cancers detected on mass CT screening. Br. J. Radiol. 2000; 73: 12529. 16 Swensen SJ, Jett JR, Hartman TE et al. CT screening for lung cancer: ve-year prospective experience. Radiology 2005; 235: 25965. 17 Lung cancer screening: recommendation statement. Ann. Intern. Med. 2004; 140: 7389. 18 Puderbach M, Hintze C, Ley S et al. MR imaging of the chest: a practical approach at 1.5T. Eur. J. Radiol. 2007; 64: 34555. 19 Takenaka D, Ohno Y, Matsumoto K et al. Detection of bone metastases in non-small cell lung cancer patients: comparison of whole-body diffusion-weighted imaging (DWI), whole-body MR imaging without and with DWI, whole-body FDG-PET/CT, and bone scintigraphy. J. Magn. Reson. Imaging 2009; 30: 298308. 20 van Beek EJ, Dahmen AM, Stavngaard T et al. Hyperpolarised 3-He MRI vs HRCT in COPD and normal volunteersPHIL trial. Eur. Respir. J. 2009; 34: 131121. 21 de Lange EE, Altes TA, Patrie JT et al. Changes in regional airow obstruction over time in the lungs of patients with asthma: evaluation with 3He MR imaging. Radiology 2009; 250: 56775. 22 Montella S, Santamaria F, Salvatore M et al. Assessment of chest high-eld magnetic resonance imaging in children and young adults with noncystic brosis chronic lung disease: comparison to high-resolution computed tomography and correlation with pulmonary function. Invest. Radiol. 2009; 44: 5328. 23 Coxson HO, Mayo J, Lam S et al. New and current clinical imaging techniques to study chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 2009; 180: 58897. 24 Kauczor HU, Ley-Zaporozhan J, Ley S. Imaging of pulmonary pathologies: focus on magnetic resonance imaging. Proc. Am. Thorac. Soc. 2009; 6: 45863. 25 Silva CI, Mller NL, Lynch DA et al. Chronic hypersensitivity pneumonitis: differentiation from idiopathic pulmonary brosis and nonspecic interstitial pneumonia by using thin-section CT. Radiology 2008; 246: 28897. Respirology (2010) 15, 393400

In fact, it has become evident that there are a number of barriers preventing its dissemination. First, development of improved or novel imaging systems and disease-specic probes is much more technically challenging than initially envisioned. Second, while imaging can be performed in animal models, moving this technology into human trials requires regulatory and compliance issues. Third, there is resistance to introduce new technology that does not clearly show an advantage over other existing imaging studies. Fourth, a molecular imaging programme requires additional infrastructure (e.g. instrumentation, radiochemistry and trained personnel), not found in most radiology departments. And nally, the largest barrier is the economics. All of these preclinical studies and human trials are expensive, and without proof of concept that this will be costeffective and impact patient care, funding is extremely difcult. Despite these concerns, molecular imaging has the potential to become an essential component of diagnostic imaging departments. The radiology community must clearly articulate the direction of this discipline, provide convincing evidence that it can be introduced into appropriate clinical scenarios, show how it replaces existing technology, demonstrate that it will be cost-effective and ultimately provide evidence that molecular imaging will inuence patient management and outcomes.

CONCLUSION
One of the broad themes that can be extracted from these commentaries is the need for a multidisciplinary approach to rene the clinical application of these increasingly sophisticated tests. Fortunately in the clinical arena this idea has been readily adopted around the world, in the form of a multidisciplinary approach to diagnosis. Such a strategy is perhaps less well developed in the sphere of imaging research (both academic and commercial), but there are signs that this concept is taking hold. In the context of research and development a fully resourced and effective multidisciplinary team should not be conned to the conventional combination of pulmonology, radiology and pathology but should have access to the skills of health economists, statisticians, physicists and computer scientists. In particular, the cost-effectiveness of many imaging tests (including the humble chest radiograph) has never been convincingly established. Indeed, this could be seen as the Achilles heel of imaging research: most of it is devoted to considerations of diagnostic accuracy and only a tiny fraction is concerned with the economic effect of introducing a new test. It is likely that in the future as much attention will be paid to the cost-effectiveness of a novel imaging technology as to its diagnostic prowess.

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